I have a prescription from my Doctor. Now what?

Use the links below to find more information about purchasing the correct medical supply products listed in your prescription. Prescription specifics are detailed below this list.

 

Bedside Commodes

Diabetic Shoes

Cushions (Wheelchair)

Hospital Beds

Lift Chair

Manual Wheelchairs

Nebulizer Compressor

Pressure Reducing Support Surfaces (Group 1)

Pressure Reducing Support (Group 2)

Oxygen

Urological Supplies

Cpaps/Bipaps

Power Mobility

 

  1. ———- A Guide to Insurance Coverage for Diabetic Shoes———-

    In order for diabetic shoes to be covered by your insurance, your provider requires we have the following items from your doctor:

    1) A prescription that includes: 

    1. your name
    2. the type of the equipment being ordered
    3. the doctor’s NPI
    4. the doctor’s signature
    5. and the date of the prescription

    2) Chart notes from your doctor. Insurance requires that you have an office visit with your doctor PRIOR to the prescription being written. The chart notes from your office visit must document the following:

    The patient has diabetes and the doctor is treating the patient under a comprehensive care plan for the diabetes.

    AND, the patient has one or more of the following conditions:

    • Previous amputation of the other foot, or part of either foot
    • History of previous foot ulceration of either foot
    • History of pre-ulcerative calluses of either foot
    • Peripheral neuropathy with evidence of callus formation of either foot
    • Foot deformity of either foot
    • Poor circulation in either foot

    3) Statement of Certifying Physician from your doctor.

     

     

    ———- A Guide to Insurance Coverage for Bedside Commodes———-

    In order for a bedside commode to be covered by your insurance, your provider requires that we have the following items from your doctor:

    1) A prescription that includes: 

    1. your name
    2. the type of the equipment being ordered
    3. the doctor’s NPI
    4. the doctor’s signature
    5. and the date of the prescription

    2) Chart notes from your doctor. Insurance requires that you have an office visit with your doctor PRIOR to the prescription being written. The chart notes from your office visit must document the following:

    The patient is confined to a single room OR

    The patient is confined to one level of the home environment and there is no toilet on that level OR

    The patient is confined to the home and there are no toilet facilities in the home.

     

     

    ———- A Guide to Insurance Coverage for Cushions (Manual & Power Wheelchairs) ———-

    In order for a cushion to be covered by your insurance, your provider requires we have the following items from your doctor:

    1) A prescription that includes: 

    1. your name
    2. the type of the equipment being ordered
    3. the doctor’s NPI
    4. the doctor’s signature
    5. and the date of the prescription

    2) Chart notes from your doctor. Insurance requires that you have an office visit with your doctor PRIOR to the prescription being written. The chart notes from your office visit must document your condition in alignment to these specifications:

    A general use cushion is covered if the patient has a manual or power wheelchair which meets Medicare coverage criteria.

    A skin protection seat cushion is covered if the patient has a Z or Power Wheelchair which meets Medicare coverage criteria and has one of the following conditions:

    • Current pressure ulcer or past history of a pressure ulcer of the lower back, coccyx, sacrum, hip, or buttock.
    • Absent or impaired sensation in the area of contact with the seating surface, or inability to carry out a functional weight shift due to one of the following diagnoses: spinal cord injury resulting in quadriplegia or paraplegia, other spinal cord disease, Multiple Sclerosis, other demyelinating disease, Cerebral Palsy, anterior horn cell diseases including Amyotrophic Lateral Sclerosis, post- Polio paralysis, Traumatic Brain Injury resulting in quadriplegia, childhood cerebral degeneration, Alzheimer’s disease, Parkinson’s disease, Muscular Dystrophy, Hemiplegia, Huntington’s Chorea, idiopathic torsion dystonia, athetoid Cerebral Palsy, Arthrogryposis, osteogenesis imperfect, spinocerebellar disease, or transverse myelitis.

    A positioning seat cushion, back cushion, or accessory is covered if a patient has a manual or power wheelchair which meets Medicare coverage criteria and has one of the following conditions:

    • Any significant postural asymmetries that are due to one of the following: spinal cord injury resulting in quadriplegia or paraplegia, other spinal cord disease, Multiple Sclerosis, other demyelinating disease, Cerebral Palsy, anterior horn cell diseases including Amyotrophic Lateral Sclerosis, post-Polio paralysis, Traumatic Brain Injury resulting in quadriplegia, childhood cerebral degeneration, Alzheimer’s disease, Parkinson’s disease, Muscular Dystrophy, Hemiplegia, Huntington’s Chorea, idiopathic torsion dystonia, athetoid Cerebral Palsy, arthrogryposis, osteogenesis imperfect, spinocerebellar disease, or transverse myelitis
    • OR Any significant postural asymmetries that are due to one of the following: monoplegia of the lower limb due to stroke, traumatic brain injury, or other etiology or spinocerebellar disease, above knee leg amputation, osteogenesis imperfect, or transverse myelitis.

    A combination skin protection and positioning seat cushionis covered for a patient who meets the criteria for both a skin protection and a positioning seat cushion.

     

     

    ———- A Guide to Insurance Coverage for Group 2 Pressure Reducing Support Surfaces———-

    (Powered Air Flotation Bed, Powered Pressure-Reducing Air Mattress, Nonpowered Advanced Pressure Reducing Overlay for Mattress, Powered Air Overlay for Mattress, Nonpowered Advanced Pressure Reducing Mattress)

    In order for a support surface to be covered by your insurance, your provider requires that we have the following items from your doctor:

    1) A prescription that includes:

    1. your name
    2. the type of the equipment being ordered
    3. the doctor’s NPI
    4. the doctor’s signature
    5. and the date of the prescription

    2) Chart notes from your doctor. Insurance requires that you have an office visit with your doctor within 6 months PRIOR to the prescription being written. The chart notes from the office visit must document the following:

    The patient has multiple stage II pressure ulcers located on the trunk or pelvis which have failed to improve over the past month, during which time the patient has been on a comprehensive ulcer treatment program including each of the following:

    • Use of an appropriate group 1 support surface
    • Regular assessment by a nurse, physician, or other licensed healthcare practitioner
    • Appropriate turning and positioning
    • Appropriate wound care
    • Appropriate management of moisture/incontinence
    • Nutritional assessment and intervention consistent with the overall plan of care OR

    The patient has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis OR

    The patient had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days.

     

    ———- A Guide to Insurance Coverage for Group 1 Pressure Reducing Support ———-

    Surfaces (Alternating Pressure Pad and Pump, Dry Pressure Mattress, Gel or Gel-Like Pressure Pad for Mattress, Air Pressure Mattress, Water Pressure Mattress, Gel Pressure Mattress, Air Pressure Pad for Mattress, Water Pressure Pad for Mattress, Dry Pressure Pad for Mattress)

    In order for a support surface to be covered by your insurance, your provider requires we have the following items from your doctor:

    1) A prescription that includes:

    1. your name
    2. the type of the equipment being ordered
    3. the doctor’s NPI
    4. the doctor’s signature
    5. and the date of the prescription

    2) Chart notes from your doctor. Insurance requires that you have an office visit with your doctor within 6 months PRIOR to the prescription being written. The chart notes from the office visit must document the following:

    The patient is completely immobile OR

    The patient has limited mobility and at least one of the conditions listed below OR

    The patient has any stage pressure ulcer on the trunk or pelvis and at least one of the following conditions:

    • Impaired nutritional status
    • Fecal or urinary incontinence
    • Alter sensory perception
    • Compromised circulatory status

     

    ———- A Guide to Insurance Coverage for Hospital Beds———-

    In order for a hospital bed to be covered by your insurance, your provider requires we have the following items from your doctor:

    1) A prescription that includes:

    1. your name
    2. the type of the equipment being ordered
    3. the doctor’s NPI
    4. the doctor’s signature
    5. and the date of the prescription

    2) Chart notes from your doctor. Insurance requires that you have an office visit with your doctor within 6 months PRIOR to the prescription being written. The chart notes from the office visit must document that a hospital bed is needed due to one of the following reasons/conditions:

    Patient requires positioning of the body in ways not feasible with an ordinary bed due to:

    • a medical condition OR
    • to alleviate pain OR
    • the patient has congestive heart failure, chronic pulmonary disease, problems with aspiration

    Or the patient requires traction equipment which can only be attached to a hospital bed.

    For a semi-electric bed, the notes must also document that the patient requires frequent changes in body position and/or has an immediate need for a change in body position.

     

    ———- A Guide to Insurance Coverage for a Lift Chair ———-

    In order for a lift chair to be covered by your insurance, your provider requires we have the following items from your doctor:

    1) A prescription that includes:

    1. your name
    2. the type of the equipment being ordered
    3. the doctor’s NPI
    4. the doctor’s signature
    5. and the date of the prescription

    2) Chart notes from your doctor. Insurance requires that you have an office visit with your doctor within 6 months PRIOR to the prescription being written. The chart notes from the office visit must document the following:

    The patient has either severe arthritis of the hip or knee OR have a severe neuromuscular disease.

    The lift chair must be a part of the physician’s course of treatment and be prescribed to effect improvement or arrest or retard deterioration in the patient’s condition.

    The patient must be completely incapable of standing up from a regular armchair or any chair in their home.

    Once standing, the patient has the ability to ambulate.

    All appropriate therapeutic modalities (medication, physical therapy, etc) have been tried and failed to enable the patient to transfer from a chair to a standing position.

     

    ———- A Guide to Insurance Coverage for Manual Wheelchairs ———-

    In order for a manual wheelchair to be covered by your insurance, your provider requires that we have the following items from your doctor:

    1) A prescription that includes:

    1. your name
    2. the type of the equipment being ordered
    3. the doctor’s NPI
    4. the doctor’s signature
    5. and the date of the prescription

    2) Chart notes from your doctor. Insurance requires that you have an office visit with your doctor within 6 months PRIOR to the prescription being written. The chart notes from the office visit must document that a manual wheelchair is needed because:

    The patient has a medical condition that makes it hard for him/her to get around inside their home and perform their daily tasks, such as toileting, feeding, dressing, grooming, and bathing .

    The patient cannot use a cane or a walker to get around inside of their home.

    The wheelchair will significantly improve the patient’s ability to get around inside of their home and the patient will use it on a regular basis.

    The patient has the upper extremity strength to self-propel a manual wheelchair or has a caregiver who is available to provide assistance with the wheelchair.

    For a lightweight wheelchair to be covered, the notes must state that the patient cannot self-propel in a standard wheelchair, and can and does self-propel in a lightweight wheelchair.

    For a high-strength lightweight wheelchair to be covered, the notes must state that the patient self-propels the wheelchair while engaging in frequent activities inside the home that cannot be performed in a standard or lightweight wheelchair AND the patient requires a seat width, depth, or height that cannot be accommodated in a standard or lightweight wheelchair AND spends at least 2 hours per day in the wheelchair.

     

    ———- A Guide to Insurance Coverage for a Nebulizer Compressor ———-

    In order for a nebulizer to be covered by your insurance, your provider requires we have the following items from your doctor:

    1) A prescription that includes:

    1. your name
    2. the type of the equipment being ordered
    3. the doctor’s NPI
    4. the doctor’s signature
    5. and the date of the prescription

    2) Chart notes from your doctor. Insurance requires that you have an office visit with your doctor within 6 months PRIOR to the prescription being written. The chart notes from the office visit must document one of the following conditions:

     

    Tuberculous Bronchiectasis Unspecified Examination-

    • Tuberculous Bronchiectasis Tubercle Bacilli Not Found by Bacteriological or Histological Examination, but Tuberculosis confirmed by other methods (Inoculation of Animals)

    Human Immonodeficiency Virus (HIV) Disease

    Pneumoncystosis

    Cystic Fibrosis with Pulmonary Manifestations

    Pneumonia due to Adenovirus-Respiratory

    Conditions due to Unspecified External Agent

    Congenital Bronchiectasis

    Abnormal Sputum

    Complications of Unspecified Transplanted Organ

    Complications of Other Specified Transplanted Organ

    Obstructive Pulmonary Disease

    Persistent thick or tenacious pulmonary secretions

     

    ———- A Guide to Insurance Coverage for Oxygen———-

    In order for Oxygen to be covered by your insurance, your provider requires we have the following items from your doctor:

    1) A prescription that includes: 

    1. your name
    2. the type of the equipment being ordered
    3. the doctor’s NPI
    4. the doctor’s signature
    5. and the date of the prescription

    2) Chart notes from your doctor. Insurance requires that you have an office visit with your doctor PRIOR to the prescription being written. The chart notes from your office visit must document the following:

    *The treating physician has determined that the patient has a severe lung disease disease or hypoxia related symptoms that might be expected to improve with oxygen therapy and

     

    *The patient’s blood gas study meets the criteria stated below and

     

    *The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services and

     

    *The qualifying blood gas study was obtained under the following conditions:

     

    If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test must be the one obtained closest to, but no earlier than 2 days prior to the hospital discharge date, or

    If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be performed while the beneficiary is in a chronic stable state – i.e., not during a period of acute illness or an exacerbation of their underlying disease, and

    *Alternative treatment measures have been tried or considered and deemed clinically ineffective

    Oxygen therapy will be denied as not reasonable and necessary if any of the following conditions are present:

    1. Angina pectoris in the absence of hypoxemia. This condition is generally not the result of a low oxygen level in the blood and there are other preferred treatments.
    2. Dyspnea without cor pulmonale or evidence of hypoxemia
    3. Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities but in the absence of systemic hypoxemia. There is no evidence that increased PO2 will improve the oxygenation of tissues with impaired circulation.
    4. Terminal illnesses that do not affect the respiratory system

     

    ———- A Guide to Insurance Coverage for Urological Supplies———-

    In order for Urological Supplies to be covered by your insurance, your provider requires we have the following items from your doctor:

    1) A prescription that includes: 

    1. your name
    2. the type of the equipment being ordered
    3. frequency of use
    4. the doctor’s signature
    5. and the date of the prescription

    2) Chart notes from your doctor. Insurance requires that you have an office visit with your doctor PRIOR to the prescription being written. The chart notes from your office visit must document the following:

     

    *The patient has permanent urinary incontinence or permanent urinary retention. Permanent urinary retention is defined as retention that is not expected to be medically or surgically corrected in that patient within 3 months.

    *The patient must have a permanent impairment of urination. This does not require a determination that there is no possibility that the patient’s condition may improve sometime in the future. If the medical record, including the judgment of the attending physician, indicates the condition is of long and indefinite duration (ordinarily at least 3 months), the test of permanence is considered met. Catheters and related supplies will be denied as noncovered in situations in which it is expected that the condition will be temporary.

    * The use of a urological supply for the treatment of chronic urinary tract infection or other bladder condition in the absence of permanent urinary incontinence or retention is non-covered. Since the beneficiary’s urinary system is functioning, the criteria for coverage under the prosthetic benefit provision are not met.

    ———- A Guide to Insurance Coverage for Cpaps/Bipaps———-

    In order for Cpaps/Bipaps to be covered by your insurance, your provider requires we have the following items from your doctor:

    1) A prescription that includes: 

    1. your name
    2. the type of the equipment being ordered
    3. frequency of use
    4. the doctor’s signature
    5. and the date of the prescription

    2) Chart notes from your doctor. Insurance requires that you have an office visit with your doctor PRIOR to the prescription being written. The chart notes from your office visit must document the following:

     

    *The beneficiary has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the beneficiary for obstructive sleep apnea.

    *The beneficiary has a sleep test (as defined below) that meets either of the following criteria (1 or 2):

            1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,
            2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
              1. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,
              2. Hypertension, ischemic heart disease, or history of stroke.

    *3) Continued coverage of a PAP device beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the treating physician must conduct a clinical re-evaluation and document that the beneficiary is benefiting from PAP therapy. Documentation of clinical benefit is demonstrated by:

     

    1. Face-to-face clinical re-evaluation by the treating physician with documentation that symptoms of obstructive sleep apnea are improved; and,
    2. Objective evidence of adherence to use of the PAP device, reviewed by the treating physician.

     

    • Adherence to therapy is defined as use of PAP ≥4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage.

     

     

    ———- A Guide to Insurance Coverage for Power Mobility Devices———-

    In order for Power Mobility Devices to be covered by your insurance, your provider requires we have the following items from your doctor:

    1) A prescription that includes: 

    1. your name
    2. the type of the equipment being ordered
    3. frequency of use
    4. the doctor’s signature
    5. and the date of the prescription

    2) Chart notes from your doctor. Insurance requires that you have an office visit with your doctor PRIOR to the prescription being written. The chart notes from your office visit must document the following:

     

    *The patient has a mobility limitation that significantly impairs his/her ability to    participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:

    Prevents the beneficiary from accomplishing an MRADL entirely, or

    Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or

    Prevents the beneficiary from completing an MRADL within a reasonable time frame.

    *The patient’s mobility limitation cannot be sufficiently and safely resolved by the use    of an appropriately fitted cane or walker.

    *The patient does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day.

    1)   Report from a Seating & Mobility Evaluation, a one-time evaluation performed by a physical or occupational therapist. The therapist documents any information that the physician did not.

    4) Seven Element Order and Detailed Product Description forms from the physician.

    5) All of this documentation is faxed to the Medicare Prior Authorization Department and they will let us know via letter within 10 business days if they approve or decline payment of the chair.